Factors associated with successful purchase of cigarettes among students aged 11–17 years who made a purchase attempt in The Gambia: Evidence from the 2017 Global Youth Tobacco Survey

INTRODUCTION Access to tobacco plays a strong role in smoking initiation among youth. This study aimed to quantify successful purchase of cigarettes and assess the factors associated with cigarette purchase access among students aged 11–17 years in The Gambia. METHODS We used the 2017 Global Youth Tobacco Survey (GYTS) of 12585 students, aged 11–17 years from The Gambia. The analysis was restricted to 2951 students aged 11–17 years who bought and/or attempted to buy cigarettes within the past 30 days regardless of smoking status. Our outcome was purchasing access, defined as successfully purchasing cigarettes within the past 30 days. We report a weighted prevalence of successful purchase attempt. Multivariable logistic regression assessed the factors associated with successful purchase of cigarettes and was adjusted for non-response and the complex survey design. RESULTS Most students (59.4%, 95% CI: 55.4–63.3) who attempted to purchase cigarettes were successful, most of whom were boys (61.3%, 95% CI: 57.8–64.6). However, there was no significant difference in successful attempts to purchase cigarettes between boys (59.3%, 95% CI: 54.2–64.2) and girls (59.4%, 95% CI: 55.4–63.3). Older age (AOR=2.45; 95% CI: 1.25–4.78), higher school grade (AOR=1.53; 95% CI: 1.09–2.16) and current cigarettes smoking (AOR=1.41; 95% CI: 1.08–1.85) were significantly associated with successful attempt to purchase cigarettes. Sex, parents’ smoking status and students’ weekly pocket money were not associated with successful cigarettes purchase attempt. Among students who currently smoke cigarettes, 55.6% (95% CI: 47.7–63.2) bought them from a store, shop, street vendor, or canteen; 12.2% (95% CI: 8.3–17.5) obtained them from someone else, and 6.7% (95% CI: 4.4–10.0) used other means the last time they smoked. CONCLUSIONS Students in The Gambia can purchase cigarettes without much hinderance despite the restrictions. Our research findings can guide the implementation of policies, programs, and public health strategies including more efforts toward implementing tobacco control laws and regulations that protect children from exposure and use of all forms of tobacco products.


INTRODUCTION
More than 80% of the one billion plus global tobacco users live in low-and middle-income countries (LMICs) 1 . Most people who smoke tobacco start smoking as children/youth, and youth initiators are more likely to be active smokers in adulthood [2][3][4] . Access to tobacco products plays a strong role in smoking initiation among youth 2,5,6 . For example, a study of secondary school students (aged 12-20 years) in The Gambia found that nearly 40% of non-smokers were susceptible to cigarette smoking, and susceptibility to cigarette smoking was more common among students who were sent to buy cigarettes 6 . Evidence has shown that early tobacco smoking initiation predicts increased chances of nicotine dependence, longer duration of smoking, and difficulty in quitting 7,8 .
Article 16 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) indicates that parties have an obligation to prohibit the sale of tobacco to youth 9 . The Gambia became a party to the WHO FCTC in 2005 and ratified it in September 2007 10 . The Ministry of Health of The Gambia has implemented a tobacco control Act and numerous policies, some of which prohibit the sale of tobacco to and by minors (aged <18 years) 11 . The Gambia has enacted several significant regulations and policies on tobacco control, including the Smoking (Prohibition in Public Places) Act 1998 12 , the Tobacco Control Act 2016 13 , and the Tobacco Control Regulations 2019 14 . Based on international treaties and local regulations, the country has the legal obligation and instruments to protect minors from exposure to tobacco. Although the Tobacco Control Act, 2016, was adopted in 2018, a year after this survey, some of the provisions, including those prohibiting sales to and by minors, came into effect immediately in 2016 13 .
Despite the numerous policy achievements in tobacco control, there remain gaps, especially regarding the implementation of regulations that protect minors. Studies in The Gambia found that 26% of boys and 9% of girls reported ever having smoked cigarettes 15 , while a subnational Global Youth Tobacco Survey conducted among youths aged 13-15 years in the capital of Banjul reported a prevalence of ever cigarette smoking among boys and girls of 29% and 20%, respectively 16 . The GYTS 2017 factsheet reported 9.2% of students aged 13-15 years currently smoke cigarettes 17 . A survey among adolescents and adults aged 15-64 years in The Gambia have shown that 66.1% were exposed to secondhand smoke in public places and the exposure levels were higher in males (79.9%) than females (58.7%) 18 .
Whereas the evidence has shown that Gambian children have access to tobacco products 6,15,19 , there have been no studies on purchase attempts and the factors associated with successful purchase attempts of cigarettes among students in The Gambia. Studies conducted in six other Sub-Saharan African countries including Ghana, Ivory Coast, Swaziland, Uganda and Republic of Congo 20 , and other studies conducted in Brazil 21 , Vietnam 22 , and China 23 have also shown a high proportion of students were successfully purchasing cigarettes. To develop stronger policies to address this issue, it is important to assess the contributing factors associated with students' access to tobacco. This study aimed to quantify successful purchase of cigarettes and assess the factors associated with successful attempt to purchase cigarettes among students aged 11-17 years in The Gambia.

METHODS
We used the 2017 Global Youth Tobacco Survey (GYTS) of 12585 students, aged 11-17 years, attending school grades 7-9 in The Gambia. Two GYTS surveys have been conducted in The Gambia. The first one was a subnational survey conducted in the capital city Banjul in 2008 16 , while the second and most recent was conducted in 2017 and is nationally representative of youths in the country with a school response rate of 100% (145/145 schools) and an individual interview response rate of 86.5% 17 . Details of The Gambia 2017 survey methodology have been published elsewhere 24 . In brief, GYTS is designed by the US Centers for Disease Control and Prevention and collaborating partners and the sample is drawn using a two-stage cluster-sampling design 25,26 . Schools are selected with probability proportional to size during the first stage, and then classes within participating schools are selected as a systematic probability sampling in the second stage 27 . Our analysis was restricted to 2951 students aged 11-17 years who bought and/or attempted to buy cigarettes within the past 30 days.

Outcome and predictor variables
The main outcome variable was cigarette purchasing access and was defined as successfully purchasing cigarettes within the past 30 days regardless of smoking status, assessed with the question: 'During the past 30 days, did anyone refuse to sell you cigarettes because of your age?' with response options 'I did not try to buy cigarettes during the past 30 days', 'Yes, someone refused to sell me cigarettes because of my age', and 'No, my age did not keep me from buying cigarettes'. Those who did not try to buy cigarettes within the past 30 days were excluded from the analysis. To determine how students who currently smoke cigarettes obtained them, we used the question: 'The last time you smoked cigarettes during the past 30 days, how did you get them?'. The responses included: from a retail outlet (including store or shop, street vendor, canteen, vending machine kiosk), from someone else, or through other means; but participants could select only one answer. The questions in the GYTS survey questionnaire are validated and other studies including one that used GYTS data from 140 countries used the above definitions 26,28,29 .
Predictor variables include age, sex, school grade, average weekly pocket money, current smoking, and parents' smoking status. Current smoking was defined as having smoked cigarettes within the past 30 days, assessed using the question: 'During the past 30 days, on how many days did you smoke cigarette?' 29 . Whether youths had ever tried or experimented with cigarettes was assessed using the question: 'Have you ever tried or experimented with cigarette smoking, even one or two puffs?' 29 . For ease of analysis, we combined the two variables on cigarette smoking into a single variable with three categories including: 'never smoked cigarettes'; 'ever tried cigarette smoking, but not currently smoking'; and 'currently smoke cigarettes'.

Statistical analysis
Our analyses accounted for the complex survey design by incorporating sampling weights and the stratification and cluster variables using the svy command in Stata (version 17). This was done to adjust for differences between the age-sex distribution of the target population and that of the achieved sample to ensure the sample was nationally representative of students aged 11-17 years. We calculated weighted prevalence (with corresponding 95% confidence intervals) of successful cigarette purchase by sociodemographics, to cigarettes by sociodemographic and other variables of interest.  Chi-squared statistical tests of association were conducted to evaluate the association. Multivariable logistic regression assessed the factors associated with successful purchase of cigarettes among children aged 11-17 years. All statistical tests were two-tailed with α=0.05. All analysis were conducted using Stata version 17. were not refused purchase because of their age ( Table  2). This was higher among students who currently smoked cigarettes (65.4%, 95% CI: 59.7-70.7) or ever tried cigarette smoking, but not currently smoking (63.8%, 95%CI: 57.0-70.0) compared with those who never smoke cigarettes (56.5%, 95% CI: 51.9-61.1) (Figure 1). Most of the students who attempted to purchase cigarettes were boys (61.2% vs 38.8%) ( Table 1), but there was no significant difference in successful attempt to purchase cigarettes between boys (59.3%, 95% CI: 54.2-64.2) and girls (59.4%, 95% CI: 55.4-63.3) ( Table 2). Successful purchase of cigarettes significantly increased with age and school grade. It was also significantly higher among students who currently smoked compared with those who did not. On how they accessed the cigarettes they most recently smoked, 55.6% (95% CI: 47.7-63.2) of students who currently smoked cigarettes bought them from a store, shop, street vendor, or canteen, 12.2% (95% CI: 8.3-17.5) obtained them from someone else, and 6.7% (95% CI: 4.4-10.0) used other means.

Factors associated with successful purchase of cigarettes
In our fully adjusted models, older age (AOR=2.45;   (Table 2). Students' sex, parents' smoking status and students' weekly pocket money were not associated with successful cigarettes purchase attempt.

DISCUSSION
Our findings indicate that most of the students (59.4%) in The Gambia who attempted to purchase cigarettes were not prevented from doing so because of their age. A high proportion of the students who attempted to purchase cigarettes were non-smokers (76.5%), and 58.5% of them were successful in purchasing cigarettes, resulting in exposing youth, who are not currently using cigarettes, to the products. Easy access to cigarettes among students who do not use tobacco as a result of lack of laws or weak implementation of regulations that protect children where they exist may lead to subsequent cigarette smoking initiation and addiction to tobacco 30,31 . Research evidence has shown that non-smoking students aged 12-20 years in The Gambia who were sent to buy cigarettes were more susceptible to initiation of tobacco smoking than those who did not have to buy cigarettes 6 .
Most of the previous studies that assessed youths' purchase access to cigarettes focused on youth who were current cigarette smokers. These include studies conducted in Brazil 21 and Vietnam 22 , as well as a study that used GYTS data from 140 countries 28 , and one that used data from six Sub-Saharan African countries 20 . In contrast, our study focused on both students who never smoked cigarettes and those who currently smoked cigarettes. Successful purchase of cigarettes among students who currently smoke cigarettes was high (65.4%), similar to findings from many other countries including a study that used GYTS data from 140 countries 28 . Studies conducted elsewhere including Ivory Coast (68.9%) 20 , South Africa (68.7%) 20 , Brazil (86.1) 21 , Vietnam (87.3% and 97.5% for boys and girls respectively) 22 , and China (80.5%) 23 have shown that a high proportion of students were successful in purchasing cigarettes. A similar study in the US has also shown that only 24.3% of youths who attempted to purchase cigarettes were refused 32 . This suggests that children/youth purchase access to cigarettes is not only a challenge in The Gambia but also in many other countries.
Our findings have shown that the majority of students aged 11-17 years in The Gambia who currently smoked cigarettes bought them from a store, shop, street vendor, or canteen. Similarly, other studies found that shops and other retail outlets were the number one source of tobacco worldwide 28,33 . Prevention of access to cigarettes at retail outlets could be a good strategy to reduce smoking initiation and the prevalence of cigarette smoking. A study that used GYTS data from India, Pakistan, Bangladesh, and Sri Lanka showed that shopkeepers' refusal to sell cigarettes to adolescents protected them from smoking 26 . As indicated in the 2016 Tobacco Control Act of The Gambia, any person who violates Section 17 (prohibition of supply of tobacco products to minors) of the Act commits an offence and is liable to a fine of ≥5000 GMD (about US$86 in 2023) or imprisonment of ≥3 months, or both, if convicted. The law also indicates that a fine of ≥100000 GMD (about US$1724 in 2023) will be imposed and the offender's license will be suspended for ≥6 months, if the offender is a corporate entity 11 . Shopkeepers should be educated on the tobacco control laws that prohibit the sale of tobacco to and by minors, as well as the implications of selling cigarettes to children. There should be strong public health measures that target cigarette vendors to avoid selling cigarettes to minors.
Older age, higher school grade and current cigarette smoking were significantly associated with a successful attempt to purchase cigarettes. Surprisingly, higher weekly pocket money and parents' smoking status were not significantly associated with a successful attempt to purchase cigarettes. This could be because 66.8% of students indicated neither of their parents' smoke and hence it is possible that mainly other adult members of the students' families and/or communities were sending them to purchase cigarettes. Parents and adults who smoke should be educated to desist from sending minors to purchase cigarettes or sharing cigarettes with them.
Some of the tobacco control laws in The Gambia were adopted (e.g. The Tobacco Control Act, 2016 13 , adopted in 2018) or passed (e.g. the Tobacco Control Regulations 2019 14 ) after the survey took place in 2017. However, some of the provisions of the Tobacco Control Act, including those prohibiting sales to and by minors, tobacco advertising, promotion and sponsorship, and smoking in public places came into effect immediately in 2016. Both the current (2021-2025) and previous tobacco control policies (2013)(2014)(2015)(2016)(2017)(2018) have provisions protecting children from access to tobacco 13 . In addition, the country signed and ratified the WHO FCTC including Article 16 10 , with a commitment to prevent the sale of tobacco to and by minors. This shows that The Gambia Ministry of Health and other stakeholders in tobacco control in the country already have the legal instruments that prohibit sale of tobacco to children 10,11,14 . There is evidence from a Cochrane Systematic Review suggesting enforcement of laws prohibiting cigarette sales to youths can lead to a reduction of smoking among youths 34 . In contrast, having laws without full implementation does not deter youths from accessing tobacco. For example, the 1993 Tobacco Products Control Act of South Africa prohibits the sale/supply of cigarettes to children aged <18 years, but the 2011 GYTS survey has shown that 68% of children aged 13-15 years who smoked cigarettes were successful in purchasing cigarettes 20 . Consistent compliance checks should be done to ensure vendors comply with the regulation. The age limit to purchase cigarettes should also be increased from 18 to 21 years and age verification conducted to avoid selling cigarettes to children.
Raising tobacco taxes, which will in turn increase the retail price, could be another effective strategy to prevent tobacco initiation among minors. As found in our previous study using the same GYTS data, increase in price deters children in The Gambia from experimenting with cigarette smoking 24 . Another study that used GYTS data from 16 African countries including The Gambia also revealed that higher cigarette prices decreased both the likelihood of smoking and smoking intensity among youth 35 .

Limitations
Although the sample size was large, the study was conducted among students and therefore the findings may not be generalizable to children out of school. The study design was cross-sectional and hence did not allow causal analysis. Smoking behavior was selfreported, and students might have the tendency to under report or over report their smoking behavior. To understand how students who smoke obtain their cigarettes, we used the question: 'The last time you smoked cigarettes during the past 30 days, how did you get them?'. Participants could pick only one response, which is a potential limitation as participants may have had access to all available options. Future surveys should ask where participants obtain products most frequently instead. Finally, the Tobacco Control Act 2016 was passed just one year before the survey. Therefore, this study cannot assess if the regulations have had a significant impact on the protection of children.

CONCLUSIONS
We found that in 2017, children in The Gambia, including never smokers, were able to purchase cigarettes without much hinderance despite current regulations. To prevent tobacco initiation at a young age, the government should increase efforts in implementing the tobacco control laws that protect children. Our findings can guide the implementation of policies, programs, and public health strategies that can protect children from exposure and use of all forms of tobacco products.